Peak Pressure Gradient Research Articles

RELATIONSHIP BETWEEN PROGRESSION OF AORTIC STENOSIS AND INFLAMMATORY CHANGE IN AORTIC VALVE IN HEMODIALYSIS PATIENTS

Abstract Category: Valvular DiseasePresentation Number: 1172-389Authors: Yoshiki Matsumura, Kenichi Sugioka, Takahiko Naruko, Takashi Omura, Tomoyuki Yamakawa, Yoshihiro Ikura, Yasuyuki Kato, Toshihi ko Shibata, Shigefumi Suehiro, Akira Itoh, Takeshi Hozumi, Minoru Yoshiyama, Makiko Ueda, Department of Internal Medicine and Cardiology, Osaka City University Graduate School of Medicine, Osaka, Japan, Department of Pathology, Osaka City University Graduate School of Medicine, Osaka, JapanBackground: In hemodialysis patients, aortic valve stenosis (AS) occurs with increased frequency and could contribute to the excess cardiovascular mortality. However, little is known about progression of AS in hemodialysis patients.Methods: The study population consisted of 30 hemodialysis patients with mild or moderate AS. They were followed up by echocardiography for a period of at least 6 months and compared to 30 non-hemodialysis patients with mild or moderate AS. Patients with decreased left ventricular function (ejection fraction <50%) at entry were excluded. Change in peak aortic valve pressure gradient (AVPG) was calculated by Doppler echocardiography. In addition, frozen aortic valve samples obtained from a different cohort of 20 AS patients with hemodialysis (n=8) and non-hemodialysis (n=12), were stained immunohistochemically with antibodies against macrophages, T-cells and endothelial cells in microvessels.Results: AS in 6 of 30 patients (20%) progressed to severe at follow-up in hemodialysis patients and 4 of 30 patients (13%) in non-hemodialysis patients. AVPG at follow-up was signiicantly increased compared with that at entry in both of hemodialysis (36+13 to 54+21 mmHg, P<0.001) and non-dialysis patients (39+6 to 50+15 mmHg, P<0.001). The rate of change in AVPG was more rapid in hemodialysis patients than non-hemodialysis patients (9.7+4.7 vs. 4.7+9.5 mmHg/year, P<0.05). Immunohistochemical stainings showed an accumulation of macrophages and T-cells and lots of microvessels in aortic valve tissues of hemodialysis patients.Conclusions: Progression of AS is more rapid in hemodialysis patients. In hemodialysis patients, the lesion of aortic valve is an active inlammatoly process with macrophage and T-cell iniltration and neoangiogenesis. An active inlammatory process in the lesion of aortic valve may be one of the mechanisms of rapid progression of AS in hemodialysis patients.

Aortic Root Replacement Using a Biovalsalva Prosthesis in Comparison to a “Handsewn” Composite Bioprosthesis

The Biovalsalva aortic root prosthesis incorporates an Elan porcine stentless biological aortic valve suspended within a triple-layered vascular conduit with preformed aortic sinuses of Valsalva. This study compared implantation of the Biovalsalva prosthesis with a "handsewn" composite bioprosthetic graft (CE Perimount bovine bioprosthesis anastomosed to a gelatin-impregnated gelweave Dacron graft). Between December 2004 and January 2009, 39 patients underwent elective or urgent aortic root replacement (modified Bentall procedure with coronary button reimplantation) using a Biovalsalva (n = 21) or a handsewn bioprosthesis (n = 18) for aortic root dilatation. There was no significant difference in the preoperative variables between the two study groups including age (70.7 +/- 1.7 vs. 67.6 +/- 2.9 years, p > 0.05). There was no in-hospital mortality. Three patients in each group underwent concomitant aortic hemi-arch replacement. Patients who underwent Biovalsalva implantation had a reduced need for transfusion of blood (1.25 +/- 0.32 vs. 3.17 +/- 0.71 units, p < 0.05) and fresh frozen plasma (2.78 +/- 0.39 vs. 1.85 +/- 0.31, p < 0.05), and reduced mediastinal blood loss (416 +/- 52 vs. 583 +/- 74 mL, p < 0.05) compared to those with a handsewn bioprosthesis. Cardiopulmonary bypass time (141 +/- 6 vs. 170 +/- 17 minutes, p = NS) and aortic cross-clamp time (113 +/- 6 vs. 115 +/- 7 minutes, p = NS) were similar. Postoperative echocardiography demonstrated excellent hemodynamic function of the Biovalsalva prosthesis (mean size 25.1 +/- 0.4 mm valved conduit) with a peak pressure gradient of 26.2 +/- 1.9 mmHg and no or trivial valvular regurgitation. The Biovalsalva prosthesis should be considered for patients requiring a biological aortic root replacement. It offers an "off-the-shelf" preassembled composite biological valve conduit with excellent hemostatic and hemodynamic properties.

Further Experience With Catheter Closure of Patent Ductus Arteriosus Using the New Amplatzer Duct Occluder in Children

The aim of the present study was to report our additional experience with transcatheter closure of the patent ductus arteriosus in 65 consecutive patients using the new Amplatzer duct occluder. The median patient age was 3.6 years (range 0.2to 12), and the median weight was 10.5 kg (range 4 to 38). The device was a modified Amplatzer duct occluder made of fabric-free fine Nitinol wire net in to 2 very low profile disks with an articulated connecting waist. It is delivered through a 4Fr to 5Fr delivery sheath. The device was permanently implanted in 62 of 65 patients. The mean patent ductus arteriosus diameter (at the pulmonary end) was 3.6 +/- 1.3 mm (range 0.5 to 5.5). The mean device diameter (waist diameter) was 4.2 +/- 1.5 mm (range 3 to 6). Complete echocardiographic closure of the PDA at 1 month follow-up was observed in 61 (98%) of 62 patients. Immediately after the procedure, mild left pulmonary stenosis (peak pressure gradient of 8, 10, and 12 mm Hg) in 3 of 63 patients. Device embolization in 1 patient was the main complication of the procedure. No other complications were observed. In conclusion, catheter closure using the Amplatzer duct occluder II is an effective and safe therapy for most patients with patent ductus arteriosus. Additional studies are required to document its efficacy, safety, and long-term results in a larger patient population.

Functional mitral stenosis after surgical annuloplasty for ischemic mitral regurgitation: Importance of subvalvular tethering in the mechanism and dynamic deterioration during exertion

Diastolic subvalvular mitral leaflet tethering by left ventricular remodeling that restricts leaflet opening in the presence of annular size reduction by surgery for ischemic mitral regurgitation potentially causes functional mitral stenosis in the absence of organic leaflet lesions. Exercise, known to worsen systolic tethering and ischemic mitral regurgitation, might also dynamically exacerbate such mitral stenosis by increasing tethering. This study evaluates the mechanism and response of such mitral stenosis to exercise. We measured the diastolic mitral valve area, annular area, and peak and mean transmitral pressure gradient by echocardiography in 20 healthy individuals and 31 patients who underwent surgical annuloplasty for ischemic mitral regurgitation. Although the mitral valve area and annular area did not significantly differ in healthy individuals (4.7 +/- 0.6 cm(2) vs 5.2 +/- 0.6 cm(2), not significant), mitral valve area was significantly smaller than the annular area in patients after annuloplasty (1.6 +/- 0.2 cm(2) vs 3.3 +/- 0.5 cm(2), P < .01). The mitral valve area was less than 1.5 cm(2) only after the surgery (P < .01) and was significantly correlated with restricted leaflet opening (r(2) = 0.74, P < .001), left ventricular dilatation (r(2) = 0.17, P < .05), and New York Heart Association functional class (P < .05). Exercise stress echocardiography of 12 patients demonstrated dynamic worsening in functional mitral stenosis (mitral valve area: 2.0 +/- 0.5 cm(2) to 1.4 +/- 0.2 cm(2), P < .01; mean pressure gradient: 1.5 +/- 0.9 mm Hg to 6.0 +/- 2.2 mm Hg, P < .01). Persistent subvalvular leaflet tethering in the presence of annular size reduction by surgery in ischemic mitral regurgitation frequently causes functional mitral stenosis at the leaflet tip level, which is related to heart failure symptoms and can be dynamic with significant exercise-induced worsening.

Stenting of aortic coarctation and exercise‐induced hypertension in the young

To evaluate whether the stenting of aortic coarctation enhance the risk of exercise-induced hypertension (EIH). There is the theoretical concern that aortic stents may cause increased aortic wall impedance and therefore systolic hypertension during exercise. Blood pressure and the Doppler derived peak and mean systolic pressure gradient (PSG and MSG) across the distal aorta at the peak of exercise were evaluated in young patients (mean age 14 +/- 3 years) with aortic coarctation successfully treated with surgery or with stent implantation at least 1 year before the test. Only patients who reached the 85% maximal predicted heart rate or whose exercise test was interrupted because of severe hypertension, and in whom significant aortic narrowings were excluded by a MRI or a CT scan performed in the six months preceding the exercise test were included in the study. Seventeen patients formed the surgery-group, while 15 patients the stent-group. Patients in surgery-group were younger at coarctation repair and with a longer follow-up than those in stent-group. No difference was present regarding age, body surface area, gender, and presence, and degree of mildly hypoplastic aortic segments between the two groups as well as between patients with or without EIH. EIH was found in 35% of surgery-group patients and in 33% of stent-group patients. PSG and MSG were similar in the patients with or without EIH. EIH can be found in a high number of young patients successfully treated for aortic coarctation but at intermediate follow-up stent implantation does not seem to enhance the risk of EIH.

Surgical Management of Left Ventricular Outflow Tract Obstruction after Biventricular Repair of Double Outlet Right Ventricle

Regardless of the preoperative morphology and the type of operation, left ventricular outflow tract obstruction (LVOTO) after biventricular repair of double outlet right ventricle (DORV) may develop. This report presents our 10-yr experience with surgical management of LVOTO after biventricular repair of DORV. Between 1996 and 2006, 15 patients underwent reoperation for subaortic stenosis after biventricular repair of DORV. The mean age at biventricular repair was 23.3±18.3 months (1.1-64.2). Biventricular repairs included tunnel constructions from the left ventricle to the aorta in 14 cases and an arterial switch operation in one. The mean left ventricle-to-aorta peak pressure gradient was 54.0±37.7 mmHg (15-140) after a mean follow-up of 9.5±6.3 yr. We performed extended septoplasty in nine patients and fibromuscular resection in six. There were no early or late mortality. There was one heart block and one aortic valve injury after an extended septoplasty, and two and one after a fibromuscular resection. No patient required reoperation for recurrent subaortic stenosis. The mean pressure gradient was 11.2±11.4 mmHg (0-34) after a mean follow-up of 5.6±2.7 yr. Extended septoplasty is a safe and effective method for the treatment of subaortic stenosis, especially in cases with a long-tunnel shaped LVOTO.

The Correlation Between Left Ventricular Failure and Right Ventricular Systolic Dysfunction Occurring in Thyrotoxicosis

Background and ObjectivesHeart failure rarely occurs in patients with thyrotoxicosis (6%), with half of the cases having left ventricular dysfunction (LVD). Although a few studies reported isolated right heart failure in thyrotoxicosis, there has been no evaluation of relationship between LVD and right ventricular dysfunction (RVD).Subjects and MethodsWe enrolled 12 patients (mean age: 51±11 years, 9 females) diagnosed as having thyrotoxicosis with heart failure and LVD {left ventricular ejection fraction (LVEF) <40%}, and divided them into two groups {Group I with RVD defined as tricuspid annular plane excursion (TAPSE) less than 15 mm and Group II without RVD}. Clinical features, laboratory variables, and echocardiographic parameters were compared between two groups.ResultsRVD was found in 6 (50%) patients. On admission, there were no significant differences between the two groups in clinical features, laboratory variables, or echocardiographic parameters including atrial fibrillation {6 vs. 5, not significant (NS)}, heart rate (149±38 vs. 148±32/min, NS), LVEF (36.7±9.5 vs. 35.1±6.3%, NS), or the tricuspid regurgitation peak pressure gradient (TRPPG, 30.9±2.0 vs. 36.3±9.3 mmHg, NS). After antithyroid treatment, all achieved an euthyroid state and both ventricular functions were recovered. All data, including the recovery time of LVEF and the change of heart rate between two groups, displayed no significant differences.ConclusionIn half of patients, RVD was combined with thyrotoxicosis-associated LVD. There were no differences in clinical factors or hemodynamic parameters between patients with and without RVD. This suggests that RVD is not secondary to thyrotoxicosis-associated LVD.

Assessment of the St. Jude Medical Regent Prosthetic Valve by Continuous-Wave Doppler and Dobutamine Stress Echocardiography

The St. Jude Medical (SJM) Regent prosthetic valve (St. Paul, MN), a recently developed mechanical valve, is an improvement on the conventional SJM valve, having a wider valve area than the SJM HP valve. We evaluated this mechanical valve by Doppler echocardiography and dobutamine stress echocardiography (DSE). The functions of the SJM Regent valve were evaluated by continuous-wave Doppler echocardiography and DES in 58 cases of aortic valve replacement during a stable postoperative period. The peak pressure gradient of the replaced valves sized 17, 19, 21, and 23 mm was 27.5 +/- 11.1, 20.0 +/- 9.8, 15.6 +/- 5.7, and 14.3 +/- 9.1, mm Hg respectively, and the effective orifice area index was 0.97 +/- 0.32, 1.01 +/- 0.29, 1.09 +/- 0.30, and 1.41 +/- 0.54 cm(2)/m(2), respectively, with prosthesis-patient mismatch (PPM) found in 1, 3, 2, and 0 cases for the 17-, 19-, 21- and 23-mm valves, respectively, with a total incidence of 10.3%. In 20 cases, the peak pressure gradient and the effective orifice area index were significantly increased during DSE compared with those at rest. Although the PPM incidence was 6.6%, it was deemed from the data of DSE and clinical symptoms that there were no clinical issues for such cases of PPM in the early and intermediate phases after operation. Particularly, the effectiveness of the 17- and 19-mm valves in patients with a small aortic annulus was demonstrated, confirming the satisfactory functions of the SJM Regent prosthetic valve.

Coarctation of the aorta treated with the Advanta V12 large diameter stent: Acute results

To report on the early results of treatment of coarctation of the aorta by dilation with a new polytetrafluoroethylene covered stent. Transcatheter dilation of aortic coarctation carries the risk of aneurysm or rupture. Covered stent implantation reduces this risk but requires a large delivery system. The Advanta V12 LD covered stent is premounted and requires a 9-11 Fr delivery system. Covered stents on balloons of a diameter sufficient to anchor the stent in the coarctation were implanted using the smallest available delivery system. Secondary dilation with larger diameter balloons was performed until the pressure gradient was <20 mm Hg and the stent was opposed to the aortic wall. Twenty-five patients with aortic coarctation underwent stent implantation. Coarctation diameter increased from (6.3 + or - 3.5) mm to (14.4 + or - 2.3) mm (P < 0.0001). Peak pressure gradient decreased from (25.3 + or - 11.6) mm Hg to (2.5 + or - 3.0) mm Hg (P < 0.0001). The stent achieved the desired diameter in all cases. There were no complications. At short-term median follow-up of 4.9 months, all patients are alive and well with no evidence of recoarctation or aneurysm. These initial results show that the covered Advanta V12LD stent is safe and effective in the immediate treatment of coarctation of the aorta through a low profile delivery system of 8-11 Fr. Long term follow up is required.

Thrombus formation due to flow competition after apico-aortic conduit

We report a case of unusual thrombus formation and describe the risk of perioperative myocardial infarction or stroke in severe aortic stenosis after apico-aortic conduit. An 86-year-old woman was admitted with aggravation of dyspnoea on exertion and chest pain. She was complicated with severe aortic stenosis and liver cirrhosis. Echocardiography demonstrated a peak pressure gradient of 50 mmHg across the aortic valve with ejection fraction of 51%. Since she had porcelain aorta and severe liver dysfunction, we selected an apico-aortic conduit under left ventricular fibrillation as treatment. Postoperative computed tomography showed a large thrombus in the descending aorta. Using strict anticoagulation therapy, the thrombus almost disappeared and thrombo-embolic events did not occur after surgery.

Covered Cheatham‐Platinum stents for serial dilatation of severe native aortic coarctation

Objectives: To report on the early results of treatment of native coarctation of the aorta by implantation and serial dilations of covered stents. Background: Transcatheter dilation of native coarctation of the aorta carries a risk of aneurysm or rupture. Covered stent implantation requires a large delivery system with the risk of vascular damage. Methods: Covered stents on balloons of diameter sufficient to anchor the stent in the coarctation were implanted using the smallest delivery system possible. Dilation with larger diameter balloons was performed until the pressure gradient was <20 mm Hg and the stent was opposed to the aortic wall. Results: Twenty-two patients with native coarctation underwent stent implantation. Coarctation diameter increased from 3.6 ± 1.9 to 12.6 ± 1.9 mm (P < 0.001). Peak pressure gradient decreased from 29.4 ± 8.5 to 6.7 ± 5.7 mm Hg (P < 0.001). Nine patients underwent further dilation on average 5 months later. Residual pressure gradient decreased from 12.3 ± 5.8 to 2.1 ± 2.9 mm Hg (P = 0.002). The stent achieved the diameter of the transverse arch in all cases. Complications included a small tear at further dilation treated with a second stent and a femoral pseudoaneurysm. At short-term follow-up of 18.5 months all patients are alive and well with no evidence of recoarctation or aneurysm. Conclusions: These initial results show that serial dilation of covered Cheatham-Platinum stents is feasible, safe, and an effective percutaneous method for the treatment of native coarctation of the aorta. However, long-term follow up is required. © 2009 Wiley-Liss, Inc.

Accessory mitral valve in an elderly man on maintenance hemodialysis.

This report describes a case of accessory mitral valve in an elderly patient on maintenance hemodialysis. Transesophageal echocardiography revealed a mobile sac-like structure with size of 12×10mm(2), which attached to the left ventricular surface of base of the anterior mitral valve leaflet. Mobile stick-like structure with diameter of 21mm was extending from this sac-like structure toward the left ventricular outflow tract and had a floating free edge. Peak pressure gradient across the left ventricular outflow tract was 32mmHg. There were no other congenital cardiac anomalies. No clinical findings suggestive of bacterial or nonbacterial vegetation were seen. Also other possibilities of mobile thrombus or calcification were unlikely. These abnormal structures were diagnosed as accessory mitral valve with rudimentary chordae.

Echocardiographic Evaluation of Diastolic Function Can Be Used to Guide Clinical Care

For normal cardiac performance, the left ventricle (LV) must be able to eject an adequate stroke volume at arterial pressure (systolic function) and fill without requiring an elevated left atrial (LA) pressure (diastolic function). These systolic and diastolic functions must be adequate to meet the needs of the body both at rest and during stress. Response by Tschope and Paulus on p 809 Systolic function is conveniently (although not always accurately) measured as the ejection fraction (EF), calculated as stroke volume divided by end-diastolic volume.1 The LV EF is easily interpreted. The lower limit of normal is ≈50%. The lower the EF is, the greater the reduction in systolic function. Diastolic function has been more difficult to evaluate.2 Traditionally, invasive measures of LV diastolic pressure-volume relations and the rate of LV pressure fall during isovolumetric relaxation have been used. However, these methods are not practical for routine clinical use and do not adequately evaluate all aspects of diastolic filling.3 Comprehensive echocardiographic evaluation of the dynamics of LV filling using blood pool and tissue Doppler has now progressed so that it provides clinically important information that can be used to direct patient care. We present data that support the use of echocardiographic evaluation of diastolic function to recognize cardiac dysfunction in patients with heart failure, especially those with preserved EF; to guide the management of patients by identifying those with and without elevated left filling pressures regardless of underlying EF; and to determine prognosis in a wide variety of patient populations. Although the LV end-diastolic pressure-volume relation describes the passive properties of the LV, LV filling is not a passive or slow process.3 In fact, the peak flow rate across the mitral valve is equal to or greater than the peak flow rate across the aortic valve. …

Echocardiographic Evaluation of Pressure Gradient across the Stent in Patients Treated for Coarctation of the Aorta

Stent placement has become a widely used method of treatment for coarctation of the aorta (COA). Our goal was to find echocardiographic indices that would correlate best with directly measured gradients across the coarctation stent. Pediatric patients with COA who underwent intra-aortic stent placement were evaluated. Patients with more than mild aortic insufficiency were excluded. Aortic pressures above and below the coarctation site were directly measured in the catheterization laboratory. Echocardiography was performed the next morning. Continuous and Pulse Doppler systolic velocity profiles proximal and distal to the stent were recorded. Statistical analysis included Pearson's correlation coefficients and linear regression between the directly measured pressure gradient and strongest correlated factor. Thirty-four patients (F : M = 15 : 19) were included in the study. The directly measured gradients (DPG) had only weak positive correlations with Doppler peak velocities (r = 0.38, P= .027) or pressure gradients (r = 0.37, P= .03) across the stent. However, there was a strong positive correlation of the directly measured gradients with the continuous wave peak systolic velocity half-time indexed to heart rate (T) (r = 0.62, P= .03), and with the squared early diastolic velocity (V(d) (2)) (r = 0.073, P < .0001). When these two parameters were combined, a linear regression equation DPG = 0.06T + 1.58 V(d) (2)- 8.05 showed very strong relations (r = 0.81, P < .0001). A simplified equation DPG = 1.98V(d) (2)+ 0.77 also accurately described the relations between the directly measured gradients and squared Doppler-measured early diastolic velocity (r = 0.71, P= .0002). A simple echocardiographic index DPG = 1.98V(d) (2)+ 0.77, where DPG is the pressure gradient across the stent, and V(d) is the early Doppler diastolic velocity, accurately describes relations between the gradient across the stent and echocardiographic data and should be used for evaluation of patients with stent-corrected COA.

Covered Cheatham‐Platinum stents for serial dilation of severe native aortic coarctation

To report on the early results of treatment of native coarctation of the aorta by implantation and serial dilations of covered stents. Transcatheter dilation of native coarctation of the aorta carries a risk of aneurysm or rupture. Covered stent implantation requires a large delivery system with the risk of vascular damage. Covered stents on balloons of diameter sufficient to anchor the stent in the coarctation were implanted using the smallest delivery system possible. Dilation with larger diameter balloons was performed until the pressure gradient was <20 mm Hg and the stent was opposed to the aortic wall. Twenty-two patients with native coarctation underwent stent implantation. Coarctation diameter increased from 3.6 +/- 1.9 to 12.6 +/- 1.9 mm (P < 0.001). Peak pressure gradient decreased from 29.4 +/- 8.5 to 6.7 +/- 5.7 mm Hg (P < 0.001). Nine patients underwent further dilation on average 5 months later. Residual pressure gradient decreased from 12.3 +/- 5.8 to 2.1 +/- 2.9 mm Hg (P = 0.002). The stent achieved the diameter of the transverse arch in all cases. Complications included a small tear at further dilation treated with a second stent and a femoral pseudoaneurysm. At short-term follow-up of 18.5 months all patients are alive and well with no evidence of recoarctation or aneurysm. These initial results show that serial dilation of covered Cheatham-Platinum stents is feasible, safe, and an effective percutaneous method for the treatment of native coarctation of the aorta. However, long-term follow up is required.

A transesophageal echocardiographic and cine-fluoroscopic evaluation of an ATS prosthetic valve opening

The effectiveness of the ATS valves includes their durability and the quietness of the valve sound. However, a cine-fluoroscopic study revealed an incomplete opening of the valve leaflet. An overall evaluation of the ATS valve was conducted by transesophageal echocardiography. The patients were divided into two groups based on the opening angle (OA): Group A, with a maximum OA of 80 degrees or greater and Group B, with a maximum OA of under 80 degrees. In Group A, the peak pressure gradient (PPG) sites of the anterior, central and posterior mitral commissure were 8.17, 8.05, and 8.09 mmHg, respectively, with no significant differences among the three sites. Similar results were obtained for Group B; the PPG at the three respective measurement sites were 8.59, 8.43, and 8.51 mmHg, and the differences were not statistically significant. No statistically significant differences were observed in the mean pressure gradient or pressure half time among the three measurement sites or between the two patient groups. Although, in many cases, the ATS valves did not open completely, the incomplete valve opening did not pose any problems in the valve function itself or in the cardiac functions of the patients.

Balloon dilation of pulmonary valve stenosis in infants less than 3 kg: A 20-year experience

This study focused on the anatomical features and outcomes of percutaneous pulmonary valve balloon dilation (PVD) in newborns < or = 3 kg in weight. Although PVD is the treatment of choice for isolated pulmonary valve stenosis, there are no studies detailing technical, anatomical, and outcome variables in the smallest of infants undergoing the procedure. A retrospective, consecutive review of all initial and follow-up echocardiograms, catheterization data, cineangiograms, and surgical records of all neonates less than 3 kg. Fifty infants underwent 55 PVD's, median age 7 days and weight 2.7 kg. Congestive heart failure and/or cyanosis were present in 55%, 46% prostaglandin dependent, with 28% having a hypoplastic right ventricle. The pulmonary valve diameter median z-score was -2.6, (range -5.8 to 1.2, P < 0.0001 vs. normal). The procedure was accomplished in all but one child, using a balloon to annulus ratio of 1.3 (range 1.1 to 1.7). There was a reduction in both the peak right ventricular systolic pressure (P < 0.0001) and outflow gradient (P < 0.0001). There was no procedure related mortality, although six children died in long-term follow-up (14%). Reintervention was necessary in 15 infants within 8 months of the procedure. Pulmonary regurgitation, present in 36% after the procedure, showed a gradual increase over time while outflow gradients decreased and valve annular dimensions increased toward normal. In infants < or = 3 kg, PVD is safe and effective. A large proportion remains free from surgery (76% at 10 years). Small valve annular dimensions show catch up growth with time.

Factors associated with development of late significant tricuspid regurgitation after successful left-sided valve surgery

Background: Persistent significant tricuspid regurgitation (TR) after successful left-sided valve surgery is frequently reported. Objectives: To evaluate the incidence, risk factors and clinical impact of development of late significant TR...

Three-Dimensional Remodeling of Cardiomyocytes in a Patient With Aortic Stenosis

A 77-year-old man was admitted to our hospital because of anterior chest pain. An echocardiogram demonstrated aortic valvular stenosis with calcification of the whole aortic root, concentric left ventricular hypertrophy, and slightly reduced left ventricular wall motion. Cardiac catheterization study showed a peak transaortic pressure gradient of 89 mm Hg and an aortic valve area of 0.52 cm2. We were planning surgical treatment, but the patient suddenly …

An Aortic Replacement with a Bioprosthesis (Carpentier-Edwards Perimount Magna) for Aortic Valve Stenosis with a Small Annulus in an Elderly Patient

An 82-year-old female was admitted to our hospital in December 2006 due to dyspnea resulting from cardiac failure accompanied by severe aortic stenosis and pulmonary hypertension. She recovered after medical treatment,but she was admitted again on May 7,2008 because of exacerbated dyspnea.Echocardiographic examination revealed aortic stenosis with a peak pressure gradient (PG)of 63 mmHg and severe tricuspidal regurgitation(TR).Cardiac catheterization showed an aortic valve area of 0.52 cm .On June 6,2008 she underwent aortic valve replacement (AVR) and tricuspid annuloplasty according to Kay’s method. Although a sizer for a Carpentier-Edwards standard prosthesis of 19 mm could not be inserted,another for a Carpentier-Edwards Perimount Magna prosthesis of 19 mm was inserted,and AVR was accomplished with this bioprosthesis while avoiding aortic annular enlargement. The patient recovered uneventfully and was discharged on the twelfth-postoperative-day.The results of postoperative echocardiography were ejection fraction 61%,mean PG 14 mmHg and,mild TR.Shinshu Med J 57 : 71―74, 2009 (Received for publication September 12,2008;accepted in revised form December 24,2008)